Thursday, November 3, 2016

Many regard Hunter S. Thompson’s book, Fear and Loathing on the Campaign Trail, which covered the 1972
Nixon versus McGovern campaign, as the best account yet of a modern U.S.
presidential campaign. Hunter’s
reporting was based on his own conversations, often over copious amounts of
alcoholic beverages (and sometimes, other illicit recreational substances) with
the people involved in both campaigns, from George McGovern himself to the
front-line worker bees whose job it was to get out the votes. In an
introduction to the 40th anniversary edition of the book, re-issued
in 2012, journalist Matt
Taibbi observedthat, “What makes the story so painful, and so
painfully funny, is that Hunter chooses the presidential campaign, of all
places, to conduct this hopeless search for truth and justice. It’s probably
worse now than it was in Hunter’s day, but the American presidential campaign
is the last place in the world a sane man would go in search of anything like
honesty. It may be the most fake place
on earth.”

I think we would agree that the 2016 American presidential
campaign is far worse than it was in Hunter’s day. Polls show that for many voters, this
election is viewed as a choice between two evils, or as Hunter put it in Fear and Loathing, “How many more of these stinking,
double-downer sideshows will we have to go through before we can get ourselves
straight enough to put together some kind of national election that will give
me and the at least 20 million people I tend to agree with a chance to vote FOR
something, instead of always being faced with that old familiar choice between
the lesser of two evils?” (I know that
many supporters of Mr. Trump or Mrs. Clinton would strongly disagree with the
“lesser evil” description of their own preferred candidate, yet polls
consistently show that both of them have historically high disapproval/approval
ratios).

Framing the election as a “lesser of two evils” choice can’t
obscure the fact that there are very real differences between Mr. Trump’s and
Mrs. Clinton’s views on just about everything—including health care
policy. They disagree on climate change
(Mrs. Clinton is for expanding on Obama’s policies to limit emissions; Mr.
Trump has said the climate change is a hoax and pledges to increase production
of fossil fuels), on firearms injury prevention (she wants to expand background
checks and limit access to assault weapons; he opposes any intrusion on an
individual’s “Second Amendment” rights to own guns, supports greater enforcement of existing laws but
opposes any new restrictions, and advocates a national “right to carry” law).

Mr.
Trump promises to repeal the Affordable Care Act (Obamacare) and replace it
with a plan that would allow people to enroll in tax-free Health Savings
Accounts to pay for their out-of-pocket costs, make premium payments by
individuals tax deductible, create state pools to insure “high risk” patients who
have not maintained continuous coverage, allow insurers to sell insurance
across state lines, and convert Medicaid to a block grant program, where the
states would get a fixed amount of federal funding per beneficiary to redesign
the program as they see fit. Mrs.
Clinton pledges to preserve, build upon and improve on the ACA by increasing
tax credit subsidies so families pay no more than 8.5% of income; working with
states to establish a public option to compete with private plans in the
marketplaces; allowing individuals aged 55-64 to buy into Medicare; create
fallback for HHS to block unreasonable rate increases; repealing the “Cadillac
Tax” on high premium employer-sponsored plans; requiring plans to cover 3 “sick” visits per
year without deductibles; creating a new tax credit of up to $2500/$5000 per
individual/family for out-of-pocket expenses in excess of 5% of income; ensuring
consumers pay no more than in-network cost-sharing for care received in a
hospital in their plan’s network (surprise bills); providing 100% federal match
for first 3 years if states adopt expansion, regardless of when they start; and
allowing undocumented immigrants to buy coverage from exchange plans at their
own cost.

The Rand
Corporation conducted an analysis of the candidate’s proposals, and
concluded that Mr. Trump’s proposals would add tens of millions of people to
the ranks of the uninsured, while Mrs. Clinton’s plan would expand coverage to tens
of millions.

No matter who the voters elect next week, however, the new President will have great
difficulty translating their plans into policies that have a chance to be
enacted into law. Should we have a
President-elect Hilary Clinton, and even if Democrats narrowly take control of
the Senate, she likely will have to deal with a Congress where the House of Representatives will still be
controlled by Republicans who have no interest in strengthening Obamacare, and
where Senate Republicans can still use the filibuster to thwart her
initiatives. And she would still have to
deal with dozens of states that will continue to be controlled by GOP governors
and legislators who are not likely to jump on the Obamacare bandwagon.

Should Mr. Trump get elected, he likely will benefit from a
Republican-controlled House and continued GOP control of the Senate. Expected Democratic gains in the Senate
though likely will make it easier for Democrats to use the filibuster to thwart
efforts to repeal Obamacare. And,
practically speaking, repealing Obamacare would mean kicking 20 million people
off of the health insurance coverage they have gained from it, pulling the plug
on federal funding of Medicaid expansion, and taking away some very popular
consumer protections, like the guarantee that insurers can’t deny coverage or
charge more to people with pre-existing conditions.

For sure, there are many things a Clinton administration
could do to strengthen the ACA through regulations should legislation become
impossible. There are things that a Trump
administration could do to ease Obamacare’s requirements on insurers and states
through regulations should legislative repeal become impossible.

Yet, unless we see a marked change in our political culture
as a reaction to the 2016 election, the current toxic stew of partisanship,
polarization, and gridlock likely will get worse before it gets better. “The
American electorate has grown increasingly divided along party lines in recent
decades, by political attitudes, social values, basic demography, and even beliefs
about reality,” observed
political scientist Gary Jacobson in an analysis published late last year
in the Annals of Political and Social Science.
“Deepening partisan divisions have inspired high levels of party-line
voting and low levels of ticket splitting, resulting in thoroughly
nationalized, president- and party-centered federal elections. Because of the
way the electoral system aggregates votes, however, historically high levels of
electoral coherence have delivered incoherent, divided government and policy
stalemate.”

The question is whether the 2016 election will lead to continuation
and even intensification of the “incoherent, divided government and policy
stalemate” that has engendered growing voter rage and historic
declines in trust in government, and even in our
democratic system of government itself?
Or act as a catharsis for voters and politicians to begin pulling us
back from the brink?

As Abraham Lincoln said in his first address to Congress in
December 1862, when our nation’s politics had grown so toxic that the country
was in the first year of a bloody civil war, “We can succeed only by
concert. It is not ‘can any of
us imagine better?’ but, ‘can we all do better?’ The dogmas of
the quiet past, are inadequate to the stormy present. The occasion is piled
high with difficulty, and we must rise –
with the occasion. As our case is new,
so we must think anew, and act anew. We must disenthrall
ourselves, and then we shall save our country?”

Now, to be clear, I don’t believe that the stakes in this
election are anywhere near what President Lincoln confronted, we aren’t going
to fall apart at the seams and start taking up arms against each other. But if we the voters don’t begin to “save our
country” by embracing politicians who believe that compromise to achieve a
common good—so “we can all do better”—is a virtue, instead of voting for those
who put their own partisan and political interests and ideological purity above
what is best for all, then we will continue to weaken and undermine our great American
democracy. This, I believe, is what we
should fear and loath most long after the ballots are counted next Tuesday.

Today’s question: What do you think is at stake in
the 2016 election, and afterwards, for healthcare, and our democracy itself?